Neuromuscular Therapy for the Boston Area

Entrapment of the lateral femoral cutaneous nerve, diagnosed medically as Meralgia Paresthetica, has been poorly understood. Obesity, pregnancy, and ill-fitting clothing are implicated, citing mechanical compression of the nerve as the cause. Treatment is conservative and usually takes several months to resolve. In a cursory search through the literature, only Travel and Simons in Myofascial Pain and Dysfunction, The Trigger Point Manualidentify a different source on pages 230-233. This medical manual is the guidebook for the Neuromuscular Therapy treatments I use to treat difficult chronic pain complaints in my office near Boston.

The last post discussed the role of the sartorius muscle in this condition. More important, in my experience, is a muscle inside the pelvis that is part of the iliopsoas, our most important hip flexor.

The iliacus muscle fills much of the space in the groin at the crease between the thigh and abdomen (look at the illustration in the previous post). The inguinal ligament attaches to the ASIS of the hip bone (ilium) next to the sartorius muscle and crosses the lower abdomen to the pubic bone. Ligaments attach bone to bone and provide a stiff and stable connection with just a little elasticity to prevent fracture at joints. Ligaments are considered “hard tissue” like bone rather than “soft tissue” like muscle. When the iliacus muscle contracts, it can swell and fill the space between the inguinal ligament and the bone of the pelvis that forms a link between the pubic bone and pelvis. That crescent shaped space is called the lacuna musculorum and contains nerves, blood vessels, the iliacus muscle belly and the psoas tendon. When the iliacus muscle contracts to flex the hip, it shortens and hardens forming a muscle bulge (like popeye) that can fill the lacuna and press on the nerves and blood vessels that run through it. The LFC nerve is tucked up in the corner right between the ASIS and the inguinal ligament, two hard tissues. Pressure from the contracted iliacus can trap the nerve and cause the symptoms of Meralgia Paresthetica, among which are burning and numbness in the skin of the outer thigh.

Treatment of the iliacus involves applying sustained pressure using NMT techniques on the muscle in two places, directly on the attachment on the inside of the hip bone (ilium) and in the groin space over the hip joint. Care must be taken by the therapist to avoid pressure on the major blood vessels there which can be clearly palpated by feeling for the pulse. A home program of hip flexor stretches is an important part of relieving the entrapment that causes numbness.

Entrapment of the lateral femoral cutaneous nerve, diagnosed medically as Meralgia Paresthetica, has been poorly understood. Obesity, pregnancy, ill-fitting clothing are implicated, citing mechanical compression of the nerve as the cause. Treatment is conservative and usually takes several months to resolve. In a cursory search through the literature, only Travel and Simons in Myofascial Pain and Dysfunction, The Trigger Point Manualidentify a different source on pages 230-233. This medical manual is the guidebook for the Neuromuscular Therapy treatments I use to treat difficult chronic pain complaints in my office near Boston.

Nerve entrapment causing numbness and burning on the skin of the outer thigh can be caused by the sartorius and the iliacus muscles. The sartorius muscle attaches to the ASIS (anterior superior iliac spine) at the front angle of the hip bone and travels diagonally across the thigh to the inner knee. To find the ASIS, place your hands on your hips with fingers facing forward so you can feel the curved top of the bone (iliac crest) with your index fingers. Feel for the angled point at the front with your middle fingers. That’s the ASIS to which attaches the sartorius muscle and the inguinal ligament. The lateral femoral cutaneous (LFC) nerve runs just under that attachment point and can sometimes pierce the sartorius muscle as it exits the pelvis. Tension in the sartorius pulls on its tendonous attachment and narrows the space beneath it, trapping the nerve. If the nerve goes through the sartorius, it squeezes it. Either way, entrapment reduces or alters sensation and function causing numbness and weakness. If the nerve gets irritated it causes the burning sensation.

Treatment of the sartorius using Neuromuscular Therapy and Active Isolated Stretching techniques relaxes the muscle, taking the pressure off the nerve and reducing the activity of Trigger Points that cause pain at the inner thigh.

The next post is about the iliacus muscle and how it causes entrapment as it passes through the lacuna musculorum at the groin.

What other joints and muscles should be considered when treating numbness in the thigh? The sacroiliac joint is one which doctors often check for symptoms referring into the butt and thigh. Although the SI joint may be involved in a pain pattern and should be treated if it is, it is not likely to be the cause of numbness in the thigh. Neither are the gluteals, although Patrick’s associated symptoms could be caused by Trigger Points from this muscle group. His symptoms start with pain and numbness in the buttocks and pain referring into the outer and inner thigh, occasionally also shooting into the groin and down into the lower leg. Pain in the butt and down as far as the lower leg are typical referrals for the gluteus minimus. Referrals into the groin could be from the quadratus lumborum, lower abdominals or local tension in the adductors, but are also caused by meralgia paresthetica (entrapment of the lateral femoral cutaneous nerve).

The Patrick’s pain is associated with weakness which developed in association with tingling. Entrapment of the sciatic nerve by the piriformis could cause symptoms of motor weakness in muscles enervated by the sciatic nerve in the posterior thigh, leg and foot. Buttock pain can also be caused by local tension of the piriformis as well as the gluteals.

Important as treating these symptoms are, the major concern was to address the numbness in the outer thigh. The sensations there included what he described as feeling like a bad sunburn. Light touch was almost unbearable although deeper pressure didn’t hurt. For this reason, my next job was to address entrapment of the lateral femoral cutaneous nerve in the pelvis.

Entrapment syndromes are regularly treated by Neuromuscular Therapy. Read the next post for more information on this nerve entrapment syndrome called meralgia paresthethica, the anatomy, symptoms and treatment with NMT.

A lower limb length inequality (LLLI) is a factor in the case of numbness in the skin on the outside of this man’s thigh. (Let’s call him Patrick.) Doing a quick check visually, there is a significant difference between the length of his legs, so he bought one of the little inexpensive heel lifts you’ll find in my Amazon store and put it in his right shoe. He said that a doctor had noticed this difference 25-30 years ago, but he hadn’t done anything about it.

In my opinion, this is the cause of Patrick’s back problem for which he has had four surgeries. Go to the SEARCH box on the right here to see several posts I’ve already written about this condition. I won’t review it again here except to say that when the pelvis in not level it can cause problems with muscles all over the body, including the inner pelvis where I suspected the real cause of numbness lay in this patient. Future failure to keep the pelvis level can cause recurring symptoms. According to Drs. Travel and Simons, once Trigger Points have developed, even an eighth of an inch difference in leg length can be a perpetuating factor for chronic pain.

To check for what the medical doctors had determined to be the cause of Patrick’s pain, I treated the muscles of the back first, 1) going deep into the little rotators and extensors on either side of the spine that can cause compression of the discs as well as 2) the longer erector muscles in the lumbar section of his back. Of course I also checked the little quadratus lumborum that levels the hip and is often the cause of low back pain and it’s associated iliolumbar ligament. (I have several posts about this too so, again, I won’t repeat here.) Both sets of muscles were tight and tender with referrals from a Trigger Point at L3, but neither reproduced the pain and numbness he was experiencing in his thigh. Releasing tension in these muscles using Neuromuscular Therapy is essential to prevent recurrence of the the disc compression.

Next I went to the sacroiliac joint and gluteal muscles that commonly refer pain into the thigh and and the piriformis that not only refers downward, but can also cause sciatic nerve entrapment.

The next post goes into other possible causes of his pain and starts to discuss the reason for the numbness.

One of my patients who was being treated for low back and butt pain is married to a man who was complaining of burning sensation in his upper and lower leg and hypersensitivity on the skin of his thighs accompanied by numbness on the outside of his thigh and pain and numbness in his butt. He had already had his fourth back surgery and was on very heavy doses of two strong medications because he couldn’t sleep at night without them. His wife was becoming alarmed, especially since she was holistically minded and fearful about possible pain drug addition for him because his symptoms were becoming chronic.

She asked me if I could help or did I know what these symptoms indicated. I felt pretty certain that the numbness in the thigh was caused by entrapment of the lateral femoral cutaneous nerve. The symptoms were classic. The surgery that had been performed wouldn’t have helped because the nerve gets entrapped in the pelvis, not in the spine.

On his last trip to the ER, the doctor suggested that he start looking into alternative therapies. He heeded the advice and came in for a visit. We talked about his symptoms and I explained what I thought it could be. He is a very smart man with some medical knowledge and an analytical mind and what I said made sense to him so we proceeded into treatment.

I explained to him that Neuromuscular Therapy was not massage, and that the treatment would be uncomfortable. He replied that it couldn’t be worse than the pain he was experiencing and told me to go ahead, just make him better!!!

Read the next post to learn what the treatment entailed and how we proceeded.

When sciatica pain gets the better of you and nothing you do seems to help, here are some self-treatment tips you can use to get pain relief. Look at other suggestions in my Checklist Part 3. (There is a list of 17 corrective actions and treatments in three parts.)

The treatment protocol I use in my Neuromuscular Therapy practice near Boston is the following:

Use some kind of massage, vibration, short application of ice or heat first. This gets the blood flowing and starts the lymphatic system draining waste products from the fluids around the muscles.

Find a place where the muscle is tender and has a tight place or a knot. If you feel any referred symptoms (sensation other than where you are pressing), it indicates that you’ve found a Trigger Point, a more important place to treat than just a place of tension.

Apply pressure with your thumb (or fingers, elbow, knuckle, a ball or some kind of pressure tool like the Theracane shown above), increasing the pressure until you increase the pain to a level 6 on a scale of 1 to 10. (Too much pain turns on your body’s alarm systems which is not helpful when you’re trying to get your muscles to relax. Too little tenderness under pressure indicates a less than optimal treatment depth.)

Hold the pressure where it hurts and count for 8 – 12 seconds. You should feel either that the muscle is softening under your pressure or the pain is subsiding, indicating that the contraction is releasing. If nothing happens, hold the pressure for up to 20 seconds. If you still feel no change, keep your thumb in the same place and let up pressure to allow the blood to get to the muscle for maybe 10 seconds, then press in again and hold until you feel a release. I suggest repeating this procedure up to three times. If you aren’t getting anywhere, go on to another place and come back to this stubborn spot.

Finish your self-treatment with more “flushing” using massage or ice or stretching.

What is better, ice or heat? That depends on your symptoms. Think of a swollen ankle. The injury has stimulated inflammation. The appropriate application is ice, not heat. Heat will increase the inflammation and swelling. So if you have pain or swelling use ice. Also use ice when you have muscle spasms. With both conditions you want to turn off the nervous system temporarily. Ice increases blood flow through the capillary beds under the skin, increasing the removal of waste products that cause pain.

Heat is used for achiness and stiffness to increase blood volume in the larger vessels, warm the muscle, and bring oxygen and nutrients. Lack of oxygen causes muscle pain, nutrients are necessary to heal the tissue.

Posture is often a factor in relieving sciatica. If you are sitting with a slumped posture, you may be compressing nerves that perpetuate your symptoms. The piriformis muscle is right under your buttocks (gluteus maximus) and is an entrapper of the sciatic nerve. Sitting back with your pelvis tucked under puts you right on top of it.

This posture can also distort the lower back (lumbar spine) from it’s normal curve. It is meant to stack up in a curve, and not curve backward. With that reverse curve position, the front edges of the vertebrae press together and can squeeze disc material out toward the back of the spine where the nerves are located. If the pressure on the nerves is sufficient or the discs are leaking fluids containing irritating chemicals, it can hurt. The position also affects the muscles, compressing some and stretching others. Constant poor positioning can cause the muscles to contract and even go into spasm.

Sleeping positions can affect sciatica symptoms also, especially sleeping on your side. Side sleeping puts pressure on the deep muscle in the side of your hip called the gluteus minimus. That muscle has been nicknamed the “pseudosciatica” muscle. If the muscle is tight, then compressed during sleep, the blood flow slows down and can cause pain from depleting oxygen supply to the muscle. Compression can also activate Trigger Points in the gluteus muscle, causing sciatica symptoms.

Side sleeping also curves the spine so it “sags.” That causes compression on the sides of the vertebrae where the nerves are located. It also causes prolonged shortening of the muscles in the side of your waist. A little muscle there called the quadratus lumborum is responsible for a majority of low back pain of muscle origin.

Repetitive movements, misuse and overuse of muscles irritate them. Think about the muscles you are using in your daily tasks. Hours of computer use, lifting heavy objects and shoveling in the garden are typical irritants, also lifting children and laundry and furniture. Lifting from a twisted position and twisting to pick up something from the floor are the most dangerous activities.

Your sport may contribute to low back tension that can lead to sciatica symptoms. Running causes repeated concussions on the spine, golf and racquet sports cause momentary stress every time the ball is hit in a twisted position. Sports that require changing direction a lot like basketball and soccer put strain on that little “pseudosciatica” muscle.

Proper stretching is necessary for maintaining healthy muscles. The Active Isolated Stretching protocol can be used for all stretches. In my opinion, and that of the many athletes who practice it, AIS is the most effective and least harmful of all the stretching methods.

Alexander Technique and Feldenkreis therapy are both excellent corrective therapies. Alexander Technique helps you feel where your spine should be in space. It teaches you how to make those corrections and gives you easier ways to perform daily movements. Feldenkreis corrects movement patterns, sometimes going back to infancy. Retraining poor movement patterns corrects irritating repetitive use of the muscles. Both therapies balance the muscles and allows them to get the R&R they need.

Nerve blocks, radiofrequency treatments, facet blocks etc. can be performed in out-patient pain clinics and hospitals. Doctors with a Pain Management specialty are the ones performing these minimally invasive procedures.

Live x-ray technology (fluoroscopy) is often used to precisely target the area that is causing your pain. In most cases you can walk out of the office and resume your normal daily activities immediately.

Nerve injections of all types are performed to block the nerve signals causing pain. Most of the injections are on the spinal nerves. These medications serve to make the nerve numb to pain.

Radiofrequency treatments “burn” nerve endings to deaden them. An electrical current produced by a radio wave is used to heat up a small area of nerve tissue, preventing it from sending pain signals.The nerves will eventually regenerate and will need to be treated again.

Facet blocks target the nerves in the facet joints that restrict twisting motions in the spine. A facet block is an injection of local anesthetic and steroid into the facet joint. More than one block may be needed depending on how many joints are involved.

Other procedures include cortisone or steroid injections for inflammation. These chemicals are very powerful and effective, but since they also kill cells, they can only be used a few times in the same spot. The source of the inflammation needs to be identified and corrected to prevent multiple anti-inflammatory injections.

Before trying these, make sure you have addressed Trigger Points with Neuromuscular Therapy and researched all other factors that may be causing your pain. See my previous checklists for reasons and explanations.

Have Trigger Point injections when appropriate (see a physiatrist usually, also medical pain specialists, neurologists and anethesiologists) Dry needling is a good option that doesn’t use an anesthetic.

To determine if you have Trigger Points, go to this previous post “Treat Trigger Points,” that shows those that cause sciatica symptoms. Manual treatment with a Trigger Point therapy like Neuromuscular Therapy usually helps. My NMT center is near Boston.

A Physiatrist is an MD, a Doctor of Physical Medicine (like a Physical Therapist with an MD). They are the ones in the rehabilitation centers that treat neuromuscular disease, chronic illness and conditions needing rehab. Physiatrists usually know about Trigger Points because it has most likely been taught in their specialty courses. Remember that Trigger Point information on sciatica pain has only been around since 1991! Other doctors who have learned about this source of pain are those who specialize in Pain Management, and sometimes anesthesiologists and neurologists. Some forward thinking PCPs have enough information to guide you to the right specialist.

Trigger Point injections are used when non-invasive treatment hasn’t helped enough. Drs. Travell and Simons in their medical text Myofascial Pain and Dysfunction: The Trigger Point Manual recommend using an “ice and stretch” treatment protocol first. When a Trigger Point is found in a taut band eliciting a “local twitch response.” the skin is cooled with ice in the direction of the muscle fibers of the taut band to turn off the nerve response. The muscle is then passively stretched.

The injection procedure involves inserting a needle in an area where TrPs are located and searching until one is found, indicated by a “jump sign.” (The muscle jumps when contacted by the needle.) A combination of a local anesthetic and saline are then injected, the anesthetic to stop the muscle from firing and the saline to flush the tissue of pain-causing elements. When this works it can stop the pain temporarily or permanently depending on several factors.

Dry needling is done by doctors but also by nurses and acupuncturists. The procedure involves inserting a needle repeatedly into a Trigger Point to break it up and is usually effective when a specific TrP is targeted. Both TrP injections and dry needling are uncomfortable, as would be expected.

Check for systemic conditions, vitamin and mineral inadequacies, food sensitivities, allergies, anemia, infections and parasites, yeast infections, toxic blood conditions, thyroid hypoactivity, circulatory disorders, acidic pH level. Limit intake of carbohydrates and other muscle stimulants like caffeine.
This is a big list, but when medical intervention and other treatments don’t give you enough pain relief from sciatica, use this checklist to be sure there is no systemic factor that is perpetuating your symptoms.

Vitamins and minerals are getting more attention now from the medical world. Essential for neuromuscular health are the Calcium complex, Vitamin C complex, and the B-complex.

Food sensitivities stimulate a full body response against the substance and allergies stimulate a full-body histamine response clogging your body’s self-cleaning organs. Anemia prevents the delivery of oxygen to your muscles, causing pain and spasm. Infections and parasites turn on the alarm systems to fight what’s wrong. Yeast organisms have 70 waste products of their own that your body has to clear before taking care of itself. Toxic blood affects everything negatively that the blood goes to. Thyroid hypoactivity (body temperature below 97.6 degrees) is common and usually causes pain. Hyperactivity rarely causes pain. Circulatory disorders mean that not enough blood is being delivered to the muscles. Acidic pH levels irritate your nerves. Carbohydrates and stimulants make your muscles tense.

Perpetuating factors are important in understanding pain. Whenever a patient in my Neuromuscular Therapy center near Boston doesn’t respond as well to treatment as I think they should, I start checking these systemic factors.